Telehealth Urgent Care for Extremely Remote Locations

Session #186, February 13, 2019

Dr. Eduardo Cordioli, MD

General Manager

Telemedicine Center

Hospital Israelita Albert Einstein

Dr. Carlos Pedrotti, MD

Clinical Staff Supervisor

Telemedicine Center

Hospital Israelita Albert Einstein

Dr. Eduardo Cordioli, MD

Has no real or apparent conflicts of interest to report.

Dr. Carlos Pedrotti, MD

Has no real or apparent conflicts of interest to report.

Conflict of Interest

• Dr. Carlos Pedrotti

– Review of literature

– The case of Off-shore Oil & Gas platforms

– How telemedicine may help offshore workers?

• Dr. Eduardo Cordioli

– How to set-up a telemedicine service on offshore platforms

– What are the main challenges

– Best practices protocols

– Real-world data

• Q/A

Agenda

• Define which are the most common urgent illnesses affecting

onboard offshore oil & gas platform personnel and quantify

effectiveness and safety of urgent care delivery by telemedicine

in that environment

• Explain in detail disembarking due to acute illness protocols

and procedures taken by telemedicine physician to assure aircraft

and patient safety during transportation

• Identify which advanced examination tools via telemedicine are

used most often, including otoscope, skin/eye/throat examination,

heart and lung auscultation, EKG and blood tests

Learning Objectives

Telehealth for Extremely Remote Locations

Medical Literature Review

Extreme Remote Locations:

1. Strategic Military Bases

2. Space Program

3. Arctic regions and Antarctica

4. Offshore Environment***

Telehealth for Extremely Remote Locations

Medical Literature Review

1. Strategic Military Bases

2. Space Program

3. Arctic Regions and Antarctica

Most remote military and Antarctic bases have physicians onsite

1,2,4

and telemedicine is mainstream for specialist consultation for

decades, considered highly successful and cost-effective

4-5.

Space

programs use telemedicine since 1957

[1] Sinderfin, CD. Telemedicine in the British Antarctic Survey Medical Unit. J Telem Telecare 1995.

[2] Ohno, G. Practical experience of telehealth between an Antarctic station and Japan. J Telem Telecare 2012.

[3] Doarn, CR. Applications of telemedicine in the United States space program. Telemed J. 1998

[4] Poropatich R. The U.S. Army Telemedicine and m-Health Program: Making a Difference at Home and Abroad. Telemedicine and E-Health 2013

[5] Grady, BJ. A Comparative Cost Analysis of an Integrated Military Telemental Health-Care Service. Telemedicine Journal and E-Health 2002

Boultinghouse

OW 2013

Videoconference

85%

Webster

, K 2008

Digital ECG

80%

[1] O.W. Boultingshouse, T.G.Jr. Fitts. Drilling Contractor, 2013.

[2] K. Webster, S. Fraser, F. Mair, J. Ferguson. Journal of Telemedicine and Telecare 2008:14:162-164.

Telehealth for Extremely Remote Locations

Medical Literature Review

4. Oil & gas Offshore Rigs:

• Reduction of unnecessary Medical Evacuations using video-

based healthcare assessment and Digital ECG

4. Oil & gas Offshore Rigs (cont):

• Shorter response times and early initiation of treatment

in critical conditions

1,2,3,4,5

• Increased patient satisfaction and perception of safety by

offshore personnel

3,6

• The petroleum industry recognizes that there are still

potentials for improvement

[1] A. Evensen, I. Fjaertoft. 2008.

[2] K. Webster, S. Fraser, F. Mair, J. Ferguson. Journal of Telemedicine and Telecare 2008:14:162-164.

[3] D.L. Anscombe, D. L. Health Care delivery for Oil Rig Workers: Telemedicine Plays a Vital Role. TELEMEDICINE and e-HEALTH, 16. 2010.

[4] F. Mika, V. Nicosia, E. Croitoru, R. Dalida, S. De Sanctis. Acta Informatica Medica 2009:17(3):155-160.

[5] W. Ponsonby, F. Mika, G. Irons. Occupational Medicine 2009:59(5):298–303.

[6] F. Mair, S. Fraser, J. Ferguson, K. Webster, K. Journal of Telemedicine and Telecare 2008:14:129-131.

[5] K. Reegrd, et al. (Eds.), 2014.

Telehealth for Extremely Remote Locations

Medical Literature Review

Case: Offshore Oil & Gas Platforms

Circa 1901 photo by G.H. Eldridge courtesy National Oceanic & Atmospheric Administration.

As recently as 1947 no company had ever

risked drilling beyond the sight of land.

Worldwide Offshore Active Rigs

Brazil

Venezuela

Gulf of Mexico

120

Gulf of Mexico

120

East

Africa 61

East

Africa 61

Mediterranean

India

175

India

175

Australia

China

148

China

148

Japan

Southeastern

Asia 83

Southeastern

Asia 83

Middle

East 252

Middle

East 252

North Sea

114

North Sea

114

Canada

Source: Baker & Hughes Rig Count Nov 2018

Global 1044Global 1044

What is life like on an oil rig?

Photograph by Mike Peel (www.mikepeel.net)

• 50-200 people onboard, many located

more than 100 miles offshore

• 2 weeks on / 2 weeks off, commute by

helicopter

• 12-hour shifts, intensive training

• Shared bedrooms and bath, self-

service style canteen with food

prepared by a chef and dedicated staff

• Gym, billiard table, pool, movie theatre,

computer room with wi-fi, Skype,

telephone (cellphones not allowed)

• 50-200 people onboard, many located

more than 100 miles offshore

• 2 weeks on / 2 weeks off, commute by

helicopter

• 12-hour shifts, intensive training

• Shared bedrooms and bath, self-

service style canteen with food

prepared by a chef and dedicated staff

• Gym, billiard table, pool, movie theatre,

computer room with wi-fi, Skype,

telephone (cellphones not allowed)

Telemedicine on offshore rigs

• Telemedicine is practiced using radio

communication since early offshore

drilling attempts

• All offshore facilites need a trained

medic onboard

• Telemedicine-based healthcare

assessment is common practice

• Today use of videoconferencing and

digital medical devices is increasingly

being adopted.

• Telemedicine is practiced using radio

communication since early offshore

drilling attempts

• All offshore facilites need a trained

medic onboard

• Telemedicine-based healthcare

assessment is common practice

• Today use of videoconferencing and

digital medical devices is increasingly

being adopted.

Photograph by Mike Peel (www.mikepeel.net)

1. HSE Healthcare and first aid on offshore installations and pipeline works. Regulation 5(1). 1989

Why Videoconferencing?

Verbal

Vocal

38%

Facial

55%

Source: Mehrabian, 1981

Telemedicine Setup

Integrated Software Platform

Health Information Management

Revised Care Protocols

Integrated Software Platform

Health Information Management

Revised Care Protocols

Equipped

Sickbay

Equipped

Sickbay

Trained

Onboard Medic

Trained

Onboard Medic

Broadband

Network

Broadband

Network

Telemedicine

Equipment

Telemedicine

Equipment

Usual Workflow

Acute Health Condition

Telemedicine station at sickbay

(onboard trained medic)

Video consultation via teleheath

with certified medical doctor

Prescription/orientation

Resolution / Observation

Evacuation

Digital Audio

HD Video

EKG

POCT Tests

Oroscopy

Otoscopy

Skin Camera

Sthetoscope

Digital Audio

HD Video

EKG

POCT Tests

Oroscopy

Otoscopy

Skin Camera

Sthetoscope

Best Practices

• Health professionals training:

• ACLS + pHTLS + ATLS

• Offshore rescue training

• Contents of medical chest

• Use of telemedicine equipment and

backup plans

• Health professionals training:

• ACLS + pHTLS + ATLS

• Offshore rescue training

• Contents of medical chest

• Use of telemedicine equipment and

backup plans

Best Practices

• Guidelines and Protocols:

• International guidelines

• Adjusted to offshore environment,

limitations and air evacuation

• Attention to detailed reporting

• Continuous communication to

occupational medicine doctors

• Guidelines and Protocols:

• International guidelines

• Adjusted to offshore environment,

limitations and air evacuation

• Attention to detailed reporting

• Continuous communication to

occupational medicine doctors

Best Practices

• Network and technology:

• HIPAA compliance

• Network Redundance

• Backup plans

• Interoperability

• Network Proactive Monitoring

• Network and technology:

• HIPAA compliance

• Network Redundance

• Backup plans

• Interoperability

• Network Proactive Monitoring

Case Report

ST-Segment Elevation Myocardial

Infaction

Mortality Increases 7,5% every 30

minutes of treatment delay

Circulation. 2004 Mar 16; 109(10):1223-5.

MPS, 63 yo (2018-03-20)

• Two hours of chest pain

• Medicated under international

protocols and monitorized

continuously by telemedicine

cardiologist.

• Evacuation delayed 4 hours due

to climate conditions

• Cath-lab enabled destination

hospital selected

• Underwent angioplasty onshore

and had a favourable prognosis

Real World Data

2017

965

video visits

6,8% Evacuations

(71,4% Non-Urgent)

93,2%

Discharged

Hospital Israelita Albert Einstein – Unpublished Data

Real World Data

Hospital Israelita Albert Einstein – Unpublished Data

28.2%

9.3%

6.5%

5.8%

4.5%

3.4%

3.3%

3.2%

3.0%

2.8%

28.5%

10%

15%

20%

25%

30%

Main Diagnosis

Real World Data

Hospital Israelita Albert Einstein – Unpublished Data

11.1%

9.5%

7.9%

6.3%

4.8%

34.9%

10%

15%

20%

25%

30%

35%

40%

Main Evac Diagnosis

Medical Devices - Mainstream

Stethoscopes Exam Cameras

Vital SignsOtoscopes

Medical Devices - Advanced

EKG Ultrasound

Medical Devices - Example

Hospital Israelita Albert Einstein – Personal Archive

Medical Devices – Real World

15.4%

5.5%

3.0%

2.2%

2.0%

1.9%

0.8%

10%

15%

20%

25%

30%

35%

40%

Devices Utilization

(other than vitals)

Hospital Israelita Albert Einstein – Unpublished Data

Medical Devices – The limits

Take Home Messages

• Adequate training of on/offshore health

professional is key

• Need for special protocols for evacuation

• Detailed reporting

• Most common reasons for medical visits are

common common colds, headaches and AGEs

• Most common medical device used is the exam

camera, and complex devices are rarely used, but

may be of great importance

• Adequate training of on/offshore health

professional is key

• Need for special protocols for evacuation

• Detailed reporting

• Most common reasons for medical visits are

common common colds, headaches and AGEs

• Most common medical device used is the exam

camera, and complex devices are rarely used, but

may be of great importance

Many thanks for your attention!

Please complete the online session evaluation

Questions

Dr. Eduardo Cordioli, MD

General Manager

Telemedicine Center

Hospital Israelita Albert Einstein

eduardo.cordioli@einstein.br

Dr. Carlos Pedrotti, MD

Clinical Staff Supervisor

Telemedicine Center

Hospital Israelita Albert Einstein

carlos.pedrotti@einstein.br